SOAP note examples you can learn from

Reading a well-written note teaches the format faster than a list of rules. This page has two full invented SOAP notes of different kinds, a commentary on the choices behind them, and a short layout to copy. The last section shows how ClearPass produces a draft like these from a conversation with the patient.

What a useful example shows

Most SOAP examples online are either too short to learn from or padded with every possible heading. The two below are written the way a busy clinician would want to read them the next time the patient comes in: specific, dated by context rather than by adjectives, and with a plan that someone else could carry out.

The first is a new acute problem. The second is a planned review of an older patient on several medicines, where the Assessment has to weigh more than one cause.

Example 1: acute gout flare

S: 57-year-old with 2 days of severe pain, redness and swelling of the left big toe joint, woke him from sleep. Similar episode 18 months ago settled in a week. Drinks 4-5 pints of beer at weekends. Takes amlodipine 5 mg daily. No fever, no injury, no other joints affected. No known drug allergies.

O: Temp 37.1. BP 138/86. Left first MTP joint hot, red, swollen, exquisitely tender; range limited by pain. Skin intact, no tophi seen. Other joints normal.

A: Probable acute gout, left first MTP, second episode. Septic arthritis considered less likely: afebrile, systemically well, typical site and history.

P: Naproxen 500 mg twice daily with food for 5 days, with omeprazole 20 mg daily while on it (clinician's decision; eGFR normal last year).
Serum urate, renal function and full blood count requested; urate to be repeated 4 weeks after the flare.
Advised to reduce alcohol and keep hydrated.
Return same day if fever, spreading redness or feeling unwell.
Review in 4 weeks to discuss long-term urate-lowering treatment.

Example 2: medication review with dizziness

S: 78-year-old attending planned medication review. Reports light-headedness on standing, worse in the mornings, for about 3 weeks. One near-fall, no loss of consciousness, no chest pain or palpitations. Started indapamide 1.5 mg 6 weeks ago in addition to ramipril 5 mg. Also takes atorvastatin 20 mg and tamsulosin 400 micrograms at night. Drinking about 1 litre of fluid a day.

O: BP sitting 132/74, standing at 3 minutes 108/66 with dizziness reproduced. HR 76 regular. Heart sounds normal, chest clear. No focal neurology. Blood from last month: sodium 133, potassium 3.6, creatinine stable.

A: Symptomatic postural hypotension, likely from combined antihypertensives and tamsulosin, possibly with low fluid intake. Mild hyponatraemia, possibly related to indapamide.

P: Indapamide stopped (clinician's decision). Ramipril and tamsulosin unchanged for now.
Advised to stand up slowly and increase fluids to about 1.5 litres a day.
Repeat sodium and renal function in 2 weeks.
Nurse lying and standing BP at that visit.
Return earlier if falls, fainting or new confusion.

Why these examples are written this way

• Durations and doses are specific. Two days and 1.5 mg can be checked later; recently and a low dose cannot.
• The Assessment names what was ruled less likely and why, so the next reader sees the reasoning, not only the label.
• Plan items say who does what: the lab test, the nurse check, the date of the next review.
• Safety-net advice is written down, because it is often the line that matters when something goes wrong.
• Each drug decision is labelled as the clinician's own. An example note is not a prescribing guide.

Short blank layout

S: complaint, history, relevant negatives, medicines, allergies
O: vitals, examination, tests available today
A: working diagnosis, reasoning, differentials
P: tests, treatment, advice, safety-net, next review

For a longer version with sub-headings, use the full SOAP note template.

Getting a draft like this from ClearPass

ClearPass drafts notes of this shape from the visit conversation. You choose SOAP, tap Transcribe after confirming consent, and talk with the patient; when you stop, the draft is ready to review. Both examples above depend on details the clinician said out loud, such as the standing blood pressure and the drug that was stopped. If a finding is never spoken or typed, it will not appear, and ClearPass does not invent it.

Any number in the draft that was not in the transcript is flagged for review. You can also type into the Ask box, for example shorten the plan or add the sodium result, and the draft is revised. From the finished note, one click gives patient instructions or a referral letter. More condition-specific examples are on pages such as SOAP note for type 2 diabetes and SOAP note for knee osteoarthritis.

What ClearPass does not do

• It does not replace your judgement. Every note is an AI draft that you review and correct before it is used.
• It is not a medical device and does not make clinical decisions. It is a documentation aid.
• It does not connect to your EMR. The note is copy-ready text that pastes into any system.

Privacy

Clinical note content is not stored on ClearPass servers: it is processed to write the note, then discarded. Consultation audio is transcribed and discarded, never stored. Your note history stays in your browser, on your device, and you choose how long it is kept. Common identifiers are removed from typed and transcribed text before it reaches the AI; that is a best-effort safeguard, so leave names, ID numbers and file numbers out where you can. Processing goes through the AI providers named in our Privacy Policy, which sets out exactly what each one receives and how long it keeps it. ClearPass does not sign HIPAA business associate agreements today.

Questions

Related

• SOAP note template
• How to write a SOAP note that colleagues can use
• SOAP note example: type 2 diabetes
• SOAP note example: knee osteoarthritis
• How to review an AI-written note